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Barriers and facilitators perceived by healthcare professionals for implementing lifestyle interventions in patients with osteoarthritis: a scoping review

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Objective: To provide an overview of barriers and facilitators that healthcare professionals (HCPs) perceive regarding the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA). Design: Scoping review. Data sources: The databases PubMed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception up to January 2021. Eligibility criteria: Primary research articles with a quantitative, qualitative or mixed-methods design were eligible for inclusion if they reported: (1) perceptions of primary and/or secondary HCPs (population); (2) on implementing LIs with physical activity and/or weight management as key components (concept) and (3) on conservative management of hip and/or knee OA (context). Articles not published in English, German or Dutch were excluded. Data extraction and synthesis: Barriers and facilitators were extracted by two researchers independently. Subsequently, the extracted factors were linked to a framework based on the Tailored Implementation for Chronic Diseases checklist. Results: Thirty-six articles were included. In total, 809 factors were extracted and subdivided into nine domains. The extracted barriers were mostly related to non-optimal interdisciplinary collaboration, patients' negative attitude towards LIs, patients' low health literacy and HCPs' lack of knowledge and skills around LIs or promoting behavioural change. The extracted facilitators were mostly related to good interdisciplinary collaboration, a positive perception of HCPs' own role in implementing LIs, the content or structure of LIs and HCPs' positive attitude towards LIs. Conclusions: Multiple individual and environmental factors influence the implementation of LIs by HCPs in patients with hip and/or knee OA. The resulting overview of barriers and facilitators can guide future research on the implementation of LIs within OA care. To investigate whether factor frequency is related to the relevance of each domain, further research should assess the relative importance of the identified factors involving all relevant disciplines of primary and secondary HCPs. Prospero registration number: CRD42019129348.
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1
BoumaSE, etal. BMJ Open 2022;12:e056831. doi:10.1136/bmjopen-2021-056831
Open access
Barriers and facilitators perceived by
healthcare professionals for
implementing lifestyle interventions in
patients with osteoarthritis: a
scoping review
Sjoukje E Bouma ,1 Juliette F E van Beek,1,2 Ron L Diercks ,1
Lucas H V van der Woude ,2,3,4 Martin Stevens ,1
Inge van den Akker- Scheek 1
To cite: BoumaSE, van
BeekJFE, DiercksRL, etal.
Barriers and facilitators
perceived by healthcare
professionals for implementing
lifestyle interventions in
patients with osteoarthritis:
a scoping review. BMJ Open
2022;12:e056831. doi:10.1136/
bmjopen-2021-056831
Prepublication history and
additional supplemental material
for this paper are available
online. To view these les,
please visit the journal online
(http://dx.doi.org/10.1136/
bmjopen-2021-056831).
MS and IvdA- S contributed
equally.
Received 30 August 2021
Accepted 07 January 2022
For numbered afliations see
end of article.
Correspondence to
Sjoukje E Bouma;
s. e. bouma@ umcg. nl
Original research
© Author(s) (or their
employer(s)) 2022. Re- use
permitted under CC BY.
Published by BMJ.
ABSTRACT
Objective To provide an overview of barriers and
facilitators that healthcare professionals (HCPs) perceive
regarding the implementation of lifestyle interventions (LIs)
in patients with hip and/or knee osteoarthritis (OA).
Design Scoping review.
Data sources The databases PubMed, Embase, CINAHL,
PsycINFO and the Cochrane Library were searched from
inception up to January 2021.
Eligibility criteria Primary research articles with a
quantitative, qualitative or mixed- methods design were
eligible for inclusion if they reported: (1) perceptions
of primary and/or secondary HCPs (population); (2) on
implementing LIs with physical activity and/or weight
management as key components (concept) and (3) on
conservative management of hip and/or knee OA (context).
Articles not published in English, German or Dutch were
excluded.
Data extraction and synthesis Barriers and facilitators
were extracted by two researchers independently.
Subsequently, the extracted factors were linked to a
framework based on the Tailored Implementation for
Chronic Diseases checklist.
Results Thirty- six articles were included. In total, 809
factors were extracted and subdivided into nine domains.
The extracted barriers were mostly related to non- optimal
interdisciplinary collaboration, patients’ negative attitude
towards LIs, patients’ low health literacy and HCPs’ lack of
knowledge and skills around LIs or promoting behavioural
change. The extracted facilitators were mostly related to
good interdisciplinary collaboration, a positive perception
of HCPs’ own role in implementing LIs, the content or
structure of LIs and HCPs’ positive attitude towards LIs.
Conclusions Multiple individual and environmental
factors inuence the implementation of LIs by HCPs in
patients with hip and/or knee OA. The resulting overview
of barriers and facilitators can guide future research on
the implementation of LIs within OA care. To investigate
whether factor frequency is related to the relevance of
each domain, further research should assess the relative
importance of the identied factors involving all relevant
disciplines of primary and secondary HCPs.
PROSPERO registration number CRD42019129348.
INTRODUCTION
Regular physical activity and weight manage-
ment are recommended by national and inter-
national clinical guidelines for the conservative
management of hip and/or knee osteoarthritis
(OA).1–5 Previous studies have demonstrated
that lifestyle interventions (LIs) focusing on
exercise, alone or combined with dietary
weight loss, are able to reduce hip and/or knee
OA- related disability and to postpone or even
prevent total joint arthroplasty.6–10 However,
these positive results are not always transferred
from research settings to daily practice, which
means that LIs are underused.11 This subop-
timal implementation of LIs as treatment for
hip and/or knee OA can result from factors
related to the patient, the healthcare profes-
sional (HCP) or the societal context.12 Research
Strengths and limitations of this study
To our knowledge, this is the rst scoping review
to classify barriers and facilitators for implementing
lifestyle interventions by healthcare professionals as
conservative treatment for hip and/or knee osteo-
arthritis in which qualitative and quantitative data
were combined.
The study population consisted of all primary and
secondary healthcare professionals involved in hip
and/or knee osteoarthritis care.
Given the broad denition of ‘implementing lifestyle
interventions’, the identied barriers and facilitators
provide insight into the full spectrum of inuencing
factors rather than being applicable to every single
way of implementing lifestyle interventions.
Grey literature was not included in the search and
selection process.
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Open access
on adhering to LIs has so far focused mainly on identifying
barriers and facilitators at the patient level. However, these
studies have also shown that HCPs can have a facilitating role
in the lifestyle behaviour of their patients, for example by
providing advice, education, encouragement and instruc-
tions.13 14
Some research has already been conducted investigating
the perspective of HCPs and the implementation of LIs in
their daily practice. This knowledge is needed in order to
enhance the implementation of LIs. As far as the authors
know, no (systematic) literature review has previously been
performed that identified and/or classified barriers and
facilitators for implementing LIs in the conservative treat-
ment of hip and/or knee OA from the perspective of all
HCPs involved. One systematic review focused on the views
towards OA management based on recommendations in
clinical practice guidelines of HCPs working in primary
care.15 However, HCPs working in secondary care are also
involved in the treatment of patients with OA, which draws
attention to the importance of collaboration and communi-
cation between primary and secondary care practitioners.16
Therefore, a scoping review was conducted aiming to
provide a comprehensive overview of barriers and facilita-
tors perceived by primary and secondary HCPs regarding
the implementation of LIs in patients with hip and/or knee
OA. The Tailored Implementation for Chronic Diseases
(TICD) checklist was used to guide data synthesis.17 Within
the context of this review, implementation was defined as the
use of LIs as conservative treatment for hip and/or knee OA
by individual HCPs.
METHOD
Study design
A scoping review has been defined as follows by Colquhoun
et al: ‘a form of knowledge synthesis that addresses an explor-
atory research question aimed at mapping key concepts,
types of evidence and gaps in research related to a defined
area or field by systematically searching, selecting and synthe-
sising existing knowledge’.18 Therefore, a scoping review was
considered a suitable methodology to summarise existing
literature on barriers and facilitators for implementing LIs
in hip and/or knee OA and to identify potential gaps in the
current literature on participation of primary and secondary
HCPs. We conducted this scoping review according to the
framework developed by Arksey and O’Malley.19 Five stages
were followed successively: (1) identifying the research ques-
tion; (2) identifying relevant studies; (3) study selection;
(4) charting the data and (5) collating, summarising and
reporting the results.19 The Preferred Reporting Items for
Systematic Reviews and Meta- Analyses Extension for Scoping
Reviews checklist was used as reporting guideline.20
Data sources and searches
A search strategy was developed consisting of four compo-
nents: search terms related to: (1) primary and secondary
HCPs; (2) hip and/or knee OA; (3) LIs and (4) barriers
and facilitators. This search strategy was applied in five
bibliographic electronic databases (ie, PubMed, Embase,
CINAHL, PsycINFO and the Cochrane Library) to iden-
tify relevant articles from inception up to 19 January 2021.
A detailed search strategy for each of the databases can
Figure 1 Flow chart of the study selection process.
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Open access
Table 1 Overview of included studies
Reference
Country and health
setting Study focus
Type of data
extracted
Data collection
method
Data analysis
method Participants
Allison (2019)27 Australia (private primary
care and public hospital
care or community
health)
Attitudes and perceptions
towards role in weight
management (knee OA)
Qualitative Individual
interviews
Inductive thematic
analysis
PT (n=13, 61%
female, age range
27–61 years)
Bossen (2016)28 The Netherlands (private
practice)
Development and feasibility
of the blended exercise
therapy intervention ‘e-
Exercise’ (hip and/or knee
OA)
Qualitative 1. Focus group
2. Individual
interviews
1. Summarising
2. Thematic trend
analysis
1. PT (n=7)
2. PT (n=5)
Christiansen
(2020)29
Canada (academic and
community family health
practice)
Experiences with and
barriers to prescribing
exercise (knee OA)
Qualitative Individual
interviews
Constant
comparison
approach
Physician (n=11)
Davis (2018)30 Canada (single
assessment centre)
Implementation of the
‘GLA:D Canada’ programme
(hip and/or knee OA)
Qualitative Individual
interviews
Thematic content
analysis
PT (n=3)
de Rooij (2014)31 The Netherlands
(rehabilitation centre)
Development of
comorbidity- adapted
exercise protocols (knee OA)
Qualitative Individual
interviews
Analysing notes PT (n=3)
Egerton (2017)*32 Australia (primary care) Perspectives on potential
barriers and facilitators
to engagement with a
proposed model of service
delivery for primary care
management (knee OA)
Qualitative Individual
interviews
Interpretive thematic
analysis
GP (n=11, 64%
female, mean age
50.8 years (range:
34–67))
Egerton (2018)*33 Australia (primary care) Barriers and facilitators
inuencing clinical practice
guideline implementation in
primary care (knee OA)
Qualitative Individual
interviews
Interpretive thematic
analysis
GP (n=11, 64%
female)
Hinman (2016)34 Australia (private
practice)
Experiences of being
involved in delivering an
integrated programme of
PT- supervised exercise and
telephone coaching (knee
OA)
Qualitative Individual
interviews
Thematic analysis
informed by
grounded theory
PT (n=10, 50%
female, mean age
43 years (SD: 13))
Telephone coach
(n=4; 100% female,
mean age 42 years
(SD: 11))
Hinman (2017)35 Australia (not specied) Experiences using Skype
as a service delivery model
for PT- prescribed exercise
management (knee OA)
Qualitative Individual
interviews
Thematic
and constant
comparative
analytical approach
PT (n=8, 50%
female, mean age
39 years (SD: 9))
Knoop (2020)36 The Netherlands
(primary care)
Feasibility of a newly
developed model of
stratied exercise therapy in
primary care (knee OA)
Qualitative 1. Individual
interviews
2. Focus group
Analysed
descriptively
1. PT (n=9)
2. PT (n=14)
Law (2019)37 UK (leisure centre) Experiences and views of
referring and delivering
professionals regarding
the ‘Lifestyle Management
Programme’ (hip and/or
knee OA)
Qualitative 1. Focus groups
2. Individual
interviews
Framework analysis
method
1. Dietician (n=2)
Exercise
professional (n=3)
PT (n=4)
Triaging clinician
(n=1)
2. GP (n=3)
Total group: 46%
female
Lawford (2019)38 Australia (private and
public practice)
Preintervention and
postintervention perceptions
of telephone- delivered
exercise therapy (knee OA)
Qualitative Individual
interviews
Thematic analysis
approach
PT (n=8, 50%
female)
Lawford (2020)39 Australia (private and
public practice)
Experiences and
perceptions with prescribing
a strengthening exercise
programme for people with
comorbid obesity (knee OA)
Qualitative Individual
interviews
Inductive thematic
approach
PT (n=7, 14%
female)
Continued
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Open access
Reference
Country and health
setting Study focus
Type of data
extracted
Data collection
method
Data analysis
method Participants
Lawford (2021)40 Australia (private and
public practice)
Experiences with a
multicomponent dietary
weight loss programme
(knee OA)
Qualitative Individual
interviews
Thematic approach
informed by
grounded theory
Dietician (n=5,
100% female)
MacKay (2018)*41 Canada (community-
based and outpatient
setting)
Factors inuencing physical
therapy management (knee
OA)
Qualitative Individual
interviews
Inductive thematic
analysis
PT (n=33, 76%
female)
MacKay (2020)*42 Canada (community-
based and outpatient
setting)
Perceptions related
to physical therapy
management (knee OA)
Qualitative Individual
interviews
Inductive thematic
analysis
PT (n=33, 76%
female)
Mann (2011)43 UK (primary and
secondary care)
Perceptions of current
service provision
and possible service
improvements (hip and/or
knee OA)
Qualitative Individual
interviews
Framework method GP (n=2)
Nurse practitioner
(n=1)
Occupational
therapist (n=1)
OS (n=2)
Practice nurse
(n=3)
PT (n=2)
RH (n=1)
Miller (2020)44 USA (large academic
medical centre)
Barriers and facilitators to
guideline- based treatment
(hip and/or knee OA)
Qualitative Individual
interviews
Conventional
content analysis
Physician (n=6,
50% female)
Nielsen (2014)45 Australia (not specied) Perspectives on and
experiences with an
intervention of exercise
combined with cognitive
behavioural therapy (Pain
Coping Skills Training) and
the implementation process
(knee OA)
Qualitative Individual
interviews
Framework analysis PT (n=8, 88%
female, age range
35–58 years)
Okwera (2019)46 UK (general practice
within NHS)
Beliefs on physiotherapy
management in primary care
(hip and/or knee OA)
Qualitative Individual
interviews
Framework analysis GP (n=8, 50%
female, age range
31–60 years)
Poitras (2010)47 France (general practice;
work setting PTs not
specied)
Barriers to use of
conservative management
recommendations (knee OA)
Qualitative Focus groups Thematic content
analysis
GP (n=7, 29%
female, median age
53 years (range:
48–77))
PT (n=10, 40%
female, median age
46.5 years (range:
24–69))
Rosemann
(2006)48
Germany (general
practice)
Problems and needs for
improving primary care (hip
and/or knee OA)
Qualitative Individual
interviews
Description of
coding process, but
no specic method
reported
GP (n=20, 20%
female, mean age
43.5 years (range:
33–57))
Practice nurse
(n=20, 100%
female, mean age
41.3 years (range:
29–56))
Selten (2017)49 The Netherlands
(general practice; work
setting PTs, OSs and
RHs not specied)
Views on non-
pharmacological, non-
surgical management (hip
and/or knee OA)
Qualitative Individual
interviews
Thematic analysis GP (n=5)
OS (n=7)
PT (n=7)
RH (n=5)
Total group: 50%
female, age range
24–64 years
Tang (2020)50 Australia (large
metropolitan public
health service)
Application of clinical
practice guidelines (knee
OA)
Qualitative Individual
interviews
Thematic analysis PT (n=18)
Teo (2020)51 Australia (private
practice and tertiary or
non- tertiary hospitals)
Experiences with delivering
care (knee OA)
Qualitative Individual
interviews
Inductive thematic
approach
PT (n=22, 50%
female, mean age
34 years (SD: 8,
range: 24–54))
Table 1 Continued
Continued
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be found in online supplemental file 1. Reference lists of
included articles were manually searched for additional rele-
vant articles. Primary research articles with a quantitative,
qualitative or mixed- methods design were eligible for inclu-
sion; study protocols, reviews, abstracts and commentaries
were excluded. Articles written in English, German or Dutch
were eligible for inclusion. No restrictions were applied
regarding publication period.
Study selection
Eligibility criteria were described according to the popu-
lation–concept–context framework.21 First, the study
Reference
Country and health
setting Study focus
Type of data
extracted
Data collection
method
Data analysis
method Participants
Wallis (2020)52 Australia (general
practice; OSs and RHs
working in private and
public hospitals)
Perceptions about
management including
barriers and enablers for
referral to the ‘GLA:D
Australia’ programme (hip
and/or knee OA)
Qualitative Individual
interviews
Inductive thematic
analysis
GP (n=5)
OS (n=6)
RH (n=4)
Total group: mean
age 52 years (SD:
12)
Cottrell (2016)53 UK (general practice) Attitudes and beliefs
regarding exercise (knee
OA)
Quantitative Survey (RR:
17%)
Descriptive statistics
(frequency)
GP (n=835, 51%
female)
Duarte (2019)54 Portugal (not specied) Development and
acceptability of the
Portuguese version of the
‘Fit & Strong!’ programme
(hip and/or knee OA)
Quantitative Survey (RR:
100%)
Not reported Programme
instructor (n=2)
Hill (2018)55 UK (specialist practice in
knee surgery)
Opinions and practices
regarding the management
of symptomatic OA in
obesity (knee OA)
Quantitative Survey (RR:
52%)
Descriptive statistics
(frequency)
OS (n=205)
Hill (2018)56 UK (general practice) Opinions and practices
regarding the management
of symptomatic OA in
obesity (knee OA)
Quantitative Survey (RR:
75%)
Descriptive statistics
(frequency)
GP (n=130)
Hofstede
(2016)57
The Netherlands (52%
of OSs worked at a
general hospital)
Barriers and facilitators
associated with prescription
of different non- surgical
treatments (hip and/or knee
OA)
Quantitative Survey (RR:
36%)
Descriptive statistics
(frequency)
OS (n=172, 9%
female, mean age
48.4 years (SD:
8.6))
Lawford (2018)58 Australia (private and
public practice)
Perceptions of remotely
delivered service models for
exercise management (hip
and/or knee OA)
Quantitative Survey (RR:
unknown)
Descriptive statistics
(frequency and level
of agreement)
PT (n=217, 72%
female)
Reid (2014)59 New Zealand (general
practice; work setting
OSs not specied)
Self- reported behaviour,
experiences, expectations
and perceptions regarding
physiotherapy referral and
management (hip and/or
knee OA)
Quantitative Survey (RR: 46%
(GP) and 26%
(OS))
Descriptive statistics
(frequency)
GP (n=24)
OS (n=20)
Total group: 34%
female, mean age
52.2 years (SD: 8.5)
de Rooij (2020)60 The Netherlands
(primary care)
Facilitators and barriers
for usage of a strategy for
exercise prescription in
patients with comorbidity
(knee OA)
Mixed- methods 1. Survey (RR:
100%)
2. Individual
interviews
1. Descriptive
statistics
(frequency)
2. Summarising
notes
1. PT (n=34, 68%
female, mean
age 43.7 years
(SD: 11.1))
2. PT (n=10)
Holden (2009)61 UK (NHS and non- NHS) Attitudes and beliefs
regarding exercise (knee
OA)
Mixed- methods 1. Survey (RR:
58%)
2. Individual
interviews
1. Descriptive
statistics (level of
agreement)
2. Thematic
analysis
1. PT (n=538,
87% female)
2. PT (n=24, 67%
female)
Kloek (2020)62 The Netherlands
(primary care practice)
Experiences with and
determinants related to
the usage of the blended
physiotherapy intervention
‘e- Exercise’ (hip and/or knee
OA)
Mixed- methods 1. Survey (RR:
40%)
2. Individual
interviews
1. Descriptive
statistics
(frequency)
2. Grounded theory
methodology
1. PT (n=49)
2. PT (n=9, 33%
female, median
age 52 years
(range: 24–59))
*Data for both studies were collected during the same interview.
GLA:D, Good Life with osteoArthritis in Denmark; GP, general practitioner; NHS, National Health Service; OA, osteoarthritis; OS, orthopaedic surgeon; PT,
physiotherapist; RH, rheumatologist; RR, response rate.
Table 1 Continued
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Table 2 Distribution of the extracted factors per included article across the domains, which were largely based on the Tailored Implementation of Chronic Diseases
checklist
Reference
Domain 1:
Intervention
factors
Domain 2:
Individual
HCP factors
Domain
3: Patient
factors
Domain 4:
Professional
interactions
Domain 5:
Incentives
and
resources
Domain 6:
Capacity for
organisational
change
Domain
7: Social,
political,
and legal
factors
Domain
8: Patient
and HCP
interactions
Domain 9:
Disease
factors
Total no of
factors in
article
Allison (2019)27 3 2 2 1 4 12
Bossen (2016)28 8 8
Christiansen (2020)29 1 5 2 1 9
Davis (2018)30 6 1 7
De Rooij (2014)31 3 2 5
Egerton (2017)32 20 3 1 9 3 1 37
Egerton (2018)33 5 9 5 6 1 1 5 32
Hinman (2016)34 7 1 2 10 20
Hinman (2017)35 18 18
Knoop (2020)36 4 1 1 6
Law (2019)37 8 1 5 1 2 1 18
Lawford (2019)38 26 26
Lawford (2020)39 11 7 1 19
Lawford (2021)40 12 3 15
MacKay (2018)41 6 5 14 7 6 2 1 41
MacKay (2020)42 4 12 5 1 1 4 27
Mann (2011)43 2 1 4 10 1 1 19
Miller (2020)44 4 4 7 3 8 1 1 1 29
Nielsen (2014)45 13 8 1 3 2 27
Okwera (2019)46 4 6 6 12 2 2 32
Poitras (2010)47 11 13 19 3 1 5 52
Rosemann (2006)48 1 4 5 4 6 1 1 1 23
Selten (2017)49 7 3 3 14 2 4 33
Tang (2020)50 12 4 1 17
Teo (2020)51 3 11 8 1 23
Wallis (2020)52 17 7 3 2 1 30
Cottrell (2016)53 12 10 4 2 3 31
Duarte (2019)54 1 2 3
Continued
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population was defined as all primary and secondary
HCPs who are involved in the conservative treatment
of patients with hip and/or knee OA. This definition
includes, respectively, HCPs providing general medical
care and HCPs providing more specialised care (with or
without a referral). Articles focusing solely on the perspec-
tive of patients with hip and/or knee OA were excluded.
Second, the concepts central to this review were barriers
and facilitators for implementing LIs. Barriers and facil-
itators were defined as any belief, experience, factor,
opinion, reason or view reported by an HCP that poten-
tially influences (either impedes or facilitates) implemen-
tation of LIs in patients with hip and/or knee OA. These
barriers and facilitators were extracted from both quan-
titative (eg, survey) and qualitative (eg, interview) data.
Implementing LIs was broadly defined, ranging from
mentioning or discussing a healthy lifestyle to recom-
mending or running specific lifestyle programmes, as
long as it was clearly described that physical activity and/
or weight management were key components. This defi-
nition includes physiotherapeutic exercise interventions
(aerobic, functional or strengthening programmes),
dietary interventions and self- management programmes.
Physiotherapeutic modalities such as acupuncture,
manual therapy, and massage, and self- management
programmes whose content was not specified were not
considered LIs and were therefore excluded. Physical
activity was also broadly defined, ranging from physical
activity during activities of daily living to participation in
supervised or non- supervised exercise therapy or sports.
Articles not primarily focusing on implementing LIs
(eg, development and evaluation of clinical guidelines,
general management of hip and/or knee OA, general
patient–practitioner relationship or shared decision
making) also fell outside the scope of this review. Lastly,
the context of this review was the conservative treatment
of hip and/or knee OA in both primary and secondary
healthcare settings. Articles focusing on preoperative or
postoperative treatment of hip and/or knee OA were
excluded. Two researchers (SB together with AJ or JvB)
independently assessed the eligibility of the identified
articles based on the above criteria in three consecutive
rounds: (1) based on title; (2) abstract and (3) full text
of the article. Any disagreements among the researchers
were resolved in consensus meetings.
Data extraction and quality assessment
A data extraction form was created and pilot- tested
in order to systematically record study characteristics
(first author, year of publication, country of origin,
aims/purpose, study design, data collection method,
data analysis method, theoretical basis, study popula-
tion, setting, recruitment method, type of LI, patient
population) and outcomes (barriers, facilitators and/
or unclear factors (ie, an influencing factor, but not
clearly defined as barrier or facilitator)). Study quality
was assessed with the Mixed Methods Appraisal Tool
(MMAT). The MMAT is a critical appraisal tool that
Reference
Domain 1:
Intervention
factors
Domain 2:
Individual
HCP factors
Domain
3: Patient
factors
Domain 4:
Professional
interactions
Domain 5:
Incentives
and
resources
Domain 6:
Capacity for
organisational
change
Domain
7: Social,
political,
and legal
factors
Domain
8: Patient
and HCP
interactions
Domain 9:
Disease
factors
Total no of
factors in
article
Hill (2018)55 5 2 7
Hill (2018)56 2 4 2 8
Hofstede (2016)57 5 3 4 1 1 14
Lawford (2018)58 33 33
Reid (2014)59 4 1 3 1 9
De Rooij (2020)60 18 8 4 9 2 1 3 45
Holden (2009)61 13 10 14 3 2 42
Kloek (2020)62 26 1 5 32
Total no of factors in
domain
315 144 137 101 56 7 9 19 21 809
HCP, healthcare professional.
Table 2 Continued
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Table 3 Overview of barriers, facilitators and unclear factors that inuence the implementation of LIs as perceived by HCPs
for all domains, which were largely based on the Tailored Implementation of Chronic Diseases checklist*
Category Subcategory—barriers Subcategory—facilitators
Subcategory—unclear
factors
Domain 1: Intervention factors (factors related to LIs)
Effectiveness LIs have little or no effect on OA29 32 33 44 46 47 49 53 59 61
Potential effects of LIs are difcult to
accomplish.47 48 53 61
LIs have positive effects on affected
joint(s).35 38 40–42 47 49 52 53 58 61
LIs have positive effects on general
health.33 40 47 49 56 57
LIs have positive mental effects.30 35 37 38 40 49 52 57
LIs have positive effects (not further
specied).34 37 44 49 52 54 57
Safety LIs are unsafe or have negative effects.39 47 52 61 LIs are safe.53 57
Research environment or protocols provide a
safety net.31 35 38 39
Design Non- optimal content or structure of LIs.34 36 52 53 62
Challenges for patients during participation in
LIs.39 40 45
Challenges for HCPs during delivery of LIs.28 30 39 60 62
Positive experiences with or suggestions
to improve the content or structure of
LIs.28 30 34 37 40 45 52 60 62
Ease for patients during participation in
LIs.39 40 52
Ease for HCPs during delivery of
LIs.30 31 34 39 45 60 62
Personalised
treatment
Insufcient ability to provide personalised treatment
within LIs.32 45 62
Ability and importance of providing personalised
treatment within LIs.37 39 42 45 47 51 53 60–62
Accessibility LIs are unavailable or inaccessible.28 33 41 43 44 53 56 59 61
Costs of LIs to patients.32 33 41 44 51 52
LIs are not feasible or sustainable.32 60
Inconvenience to patients when accessing LIs.51–53
LIs are available or accessible, or suggestions
for improvement.32 37 41 46 57 59
LIs are feasible or sustainable.32 36 37 42 60
Convenience for patients when accessing LIs.52
Telehealth Disadvantages of telehealth in terms of
effectiveness32 58 62
Telehealth is not safe for patients or patient/data
privacy.32 58
Challenges for HCPs regarding lack of physical/visual
contact.35 38 58 62
Other challenges for HCPs regarding feasibility of
telehealth.28 32 35 38 58 62
Patient- related challenges regarding feasibility of
telehealth.28 32 62
Negative aspects regarding communication and
relationship using telehealth.34 35 38 40
Benets of telehealth in terms of
effectiveness.28 35 38 58 62
Telehealth is safe for patients or patient/data
privacy.35 58 62
Lack of physical/visual contact not a major
issue for HCPs.35 38 58
Positive attitude or needs of HCPs regarding
feasibility of telehealth.35 38 40 58 62
Patient- related benets regarding feasibility of
telehealth.28 32 35 38 58
Positive aspects regarding communication and
relationship using telehealth.38 40
Domain 2: Individual HCP factors (factors related to individual primary and secondary HCPs)
Expertise Lack of knowledge or skills around LIs or promoting
behavioural change.27 29 33 41 42 45 47 49–51 56 60 61
Lack of knowledge or skills around OA care in
general.43 44 46 48
Lack of knowledge or skills around specic
resources.33 50 60
Having or improving knowledge or skills
around LIs or promoting behavioural
change.33 34 41 42 45 46 50
Having or improving knowledge or skills around
OA care in general.33 44 46 48
Available resources might improve knowledge
and decision- making.31 50 60
Clinical experience42
Attitude Negative attitude towards LIs.29 53 61
Negative attitude towards guidelines or protocols.46
Positive attitude towards
LIs.33 41 42 45–47 50 51 53 55–57 59
Positive attitude towards guidelines or
protocols.27 57 60
Autonomy37
Role Perception of own role potentially impeding
prescription or follow- up of LIs.29 33 42 44 47–51 53 55 61
Negative consequences for own role when referring
patients to LIs.32
Perception of own role potentially
stimulating prescription or follow- up of
LIs.33 41 42 47 48 51 53 55 56 61
Positive consequences for own role when
referring patients to LIs.32
Domain 3: Patient factors (factors related to patients with hip and/or knee OA)
Health status Severity of disease and symptoms.32 44 47 50 52 61
Negative impact of comorbidities.29 39 44 47 48 51 52
Other patient characteristics.47 52 59
Severity of disease and symptoms.39 47 53 59 61
Other patient characteristics.41 51 59
Severity of disease and
symptoms.42 46 53 61
Other patient
characteristics.41
Treatment
expectations and
preferences
Negative attitude towards LIs29 33 34 36 39 41–48 51–53 60 61
Positive attitude towards TJA37 43 48
Make use of patients’ preference for TJA within
LIs37
Patients’ preferences46
Active participation Low patient adherence or
engagement33 37 41 42 46 47 51 54 61
High patient adherence or engagement34 39 40 54
Importance of high patient adherence or
engagement for effectiveness of LIs30 41 42 47 53 61
Continued
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can be used in reviews of mixed studies to assess the
methodological quality of different study design cate-
gories: mixed- methods, qualitative and quantitative
studies (randomised controlled trials, non- randomised
studies and descriptive studies).22 23 Since calculating a
total score is discouraged,23 it was chosen to present the
ratings of the individual criteria.
Data extraction was performed in two stages. The first
stage consisted of filling in the data extraction form and
the MMAT for each article, done by two researchers
(SB/JvB) independently. Regarding barriers and facil-
itators, both researchers extracted the relevant units
of text and/or descriptive statistics from the Results
sections. Any discrepancies between the researchers
in this first stage were resolved in consensus meetings.
During the second stage, the extraction of barriers and
facilitators was discussed among the research team
(SB/MS/IvdA- S) and the process was further refined
for both quantitative and qualitative data. Regarding
quantitative data, factors were only extracted if 50%
of participants indicated that the factor influenced the
implementation of LIs.24 25 For close- ended questions
or attitude statements with multiple answer options,
participants were classified as being ‘in agreement’
or ‘not in agreement’. If this classification had not
yet been made by the authors of the original article,
it was made based on the possible answer options,
with ‘(strongly) agree’, ‘to a reasonable/large extent’
and ‘yes’ indicating agreement, and ‘neither disagree
or agree’, ‘don’t know’, ‘neutral’, ‘a little bit/not at
all’, ‘(strongly) disagree’, and ‘no’ indicating not in
agreement. Next, the factor was classified as barrier or
Category Subcategory—barriers Subcategory—facilitators
Subcategory—unclear
factors
Capabilities Low health literacy33 37 39–41 43 44 47 49 51 52 60 61
Limited nancial resources41 44
Other responsibilities41 45
High health literacy or importance of
education39 42 43 49 51 60
Social support40 48
Health literacy46
Other responsibilities41
Domain 4: Professional interactions (factors related to interactions between primary and secondary HCPs)
Collaboration Non- optimal interdisciplinary collaboration or
healthcare provision27 32 34 41 43 46 47 49 53 60
No access to other HCPs4152
Good interdisciplinary collaboration or
healthcare provision, or suggestions for
improvement27 32 34 37 41 43 44 46–49 52 53 55–57 59 60 62
Access to other HCPs32 41–43 46
Communication
and referral
Lack of communication between HCPs46 48 60
Challenges of communication and referral
procedures34 36 44 46 60
Improving communication between
HCPs32 34 46 48 52 57
Needs regarding communication and referral
procedures32 41 46 49 52
Domain 5: Incentives and resources (factors related to the availability of incentives and resources for primary and secondary HCPs)
Time Lack of time within patient consultations33 43–45 49 53 61
Lack of time due to other demands (or not further
specied)32 37 41 48 62
Adequate duration of patient consultations33 41
Adequate duration of specic interventions or
protocols32 45 60 62
Financial resources Limited nancial resources within organisation45 48 Financial reward for implementing LIs32 48 60
Information
resources
Lack of information resources27 37 44 48
Challenges in accessing information resources41 44 53
Availability of information resources27 44 52 57
Access to information resources33 41 42 52
Facilities Negative attitude towards information technology33 Potential use of information technology33 44
Benets of working in health centres49
Domain 6: Capacity for organisational change (factors related to the organisation where primary and secondary HCPs work)
Professional
paradigm
Adequate professional paradigm or suggestions
for expansion27 41 45
Monitoring Audit57
Support within the
organisation
Management not supportive60
Domain 7: Social, political, and legal factors (factors related to the social, political and legal context)
Healthcare system Restrictions due to health insurance41 48 60 Benets of good health insurance44 46 60
Government subsidies33
Domain 8: Patient and HCP interactions (factors related to interactions between patients with hip and/or knee OA and primary and secondary HCPs)
Therapeutic alliance Potential negative inuence of implementing LIs to
relationship37
Importance of communication and
relationship39 42 48 49
Lifestyle as
conversation topic
Challenges of discussing weight27 33 42 49 50 Factors that could ease the way to discussing
weight27 42 44 47 49
Domain 9: Disease factors (factors related to OA)
Image OA seen as low priority29 32 43 46–48
OA seen as untreatable and local condition (wear- and-
tear)33 44 46 47 51 52 61
Optimistic views towards OA33 47
HCP, healthcare professional; LI, lifestyle intervention; OA, osteoarthritis; TJA, total joint arthroplasty.
Table 3 Continued
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facilitator depending on the formulation of the ques-
tion and which of the two groups (‘in agreement’ vs
‘not in agreement’) comprised 50% of the partici-
pants. In case of open- ended questions, all mentioned
factors were extracted. Regarding qualitative data,
if the authors of the original study did not explicitly
identify a factor as barrier or facilitator, the descrip-
tion in the text or the participants’ quotes were used
to classify the factor as barrier (ie, impeding/negative/
problem/lack), facilitator (ie, facilitating/positive/
solution/need) or unclear (ie, insufficient informa-
tion). In addition, all unclear factors were rediscussed
with a third researcher (IvdA- S) to assess whether these
factors could nevertheless be classified as barrier or
facilitator. At the end of the second stage, final data
extraction based on the above criteria was performed
Figure 2 Overview of the number of barriers and facilitators per category. The domain numbers indicated in brackets refer
to the domains as presented in table3: (1) intervention factors; (2) individual HCP factors; (3) patient factors; (4) professional
interactions; (5) incentives and resources; (6) capacity for organisational change; (7) social, political and legal factors; (8) patient
and HCP interactions and (9) disease factors. Unclear factors were not included in this gure due to the low number (n=11).
Table 4 Ranking of the ten largest subcategories of barriers
Rank Subcategory of barriers (domain) Factors (n)
1 Non- optimal interdisciplinary collaboration or healthcare provision (4—professional interactions) 31
2 Negative attitude towards LIs (3—patient factors) 28
3 Low health literacy (3—patient factors) 24
Lack of knowledge or skills around LIs or promoting behavioural change (2—individual HCP factors) 24
5 Perception of own role potentially impeding prescription or follow- up of LIs (2—individual HCP factors) 23
6 Severity of disease and symptoms (3—patient factors) 17
7 Other challenges for HCPs regarding feasibility of telehealth (1—intervention factors) 16
8 LIs have little or no effect on OA (1—intervention factors) 14
9 Lack of time within patient consultations (5—incentives and resources) 12
LIs are unavailable or inaccessible (1—intervention factors) 12
HCP, healthcare professional; LI, lifestyle intervention; OA, osteoarthritis.
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by one researcher (SB), who also checked the consis-
tency of the entire data extraction process.
Data synthesis and analysis
A narrative synthesis of the data was undertaken, based
on the TICD checklist developed by Flottorp et al.17 This
checklist aims to assist in identifying key determinants
of professional practice, defined as factors that might
prevent or enable healthcare improvements, and is
intended for use in research on implementation and
quality improvement in healthcare. It consists of seven
domains: (1) guideline factors; (2) individual health
professional factors; (3) patient factors; (4) profes-
sional interactions; (5) incentives and resources; (6)
capacity for organisational change; and (7) social, polit-
ical and legal factors. The authors of the current study
have previously used the TICD checklist in the analysis
of focus group data on the same topic, revealing two
additional domains: (8) patient and HCP interactions;
and (9) disease factors.26 One researcher (SB) assigned
all extracted factors to one of these nine domains and
then inductively developed different categories and
subcategories of factors per domain. The resulting
classification of factors and corresponding conclusions
were subsequently discussed among the research team
(SB/MS/IvdA- S).
Patient and public involvement
Patients or the public were not involved in this study as
the study aim did not concern patients but HCPs.
RESULTS
Study selection
A flow chart of the study selection process is presented
in figure 1. A total of 8338 articles were retrieved. After
removal of duplicates and exclusion of articles based
on title or abstract, 93 potentially relevant articles
remained for full- text screening. Ultimately, 36 articles
were included in the qualitative synthesis.27–62
Study characteristics
General characteristics of the included studies are
presented in table 1. The majority of studies were
conducted in Australia (36%), the Netherlands (19%),
the UK (19%) and Canada (11%). Qualitative data
were extracted in 26 studies (72%), quantitative data
in 7 studies (19%), and both qualitative and quantita-
tive data in the remaining 3 studies (8%). Individual
interviews were most commonly used as qualitative
data collection method, while the quantitative studies
were all based on cross- sectional surveys. Most studies
included physiotherapists or general practitioners (or
physicians) as study population. Other participants were
dieticians, exercise professionals, a nurse practitioner,
an occupational therapist, orthopaedic surgeons, prac-
tice nurses, programme instructors, rheumatologists,
telephone coaches and triaging clinicians.
Quality assessment
Findings of the quality assessment of the included
studies based on the MMAT are shown in online supple-
mental file 2. Regarding the qualitative data assess-
ments, only one study had the maximum of five positive
ratings. Seven studies had a negative rating for the item
on substantiating the interpretation of results, as no or
a limited number of participant quotes were presented.
In addition, many unknown ratings were given due
to a lack of information about the applied qualitative
approach and/or data analysis methods and their ratio-
nale. Regarding the quantitative data assessments, most
studies had a negative or unknown rating for the risk of
non- response bias due to low response rates or a lack of
Table 5 Ranking of the ten largest subcategories of facilitators
Rank Subcategory of facilitators (domain) Factors (n)
1 Good interdisciplinary collaboration or healthcare provision, or suggestions for improvement (4—
professional interactions)
40
2 Perception of own role potentially stimulating prescription or follow- up of LIs (2—individual HCP
factors)
27
3 Positive experiences with or suggestions to improve the content or structure of LIs (1—intervention
factors)
24
4 Positive attitude towards LIs (2—individual HCP factors) 22
5 Positive attitude or needs of HCPs regarding feasibility of telehealth (1—intervention factors) 18
Ease for HCPs during delivery of LIs (1—intervention factors) 18
7 LIs have positive effects on affected joint(s) (1—intervention factors) 17
8 Patient- related benets regarding feasibility of telehealth (1—intervention factors) 16
9 Ability and importance of providing personalised treatment within LIs (1—intervention factors) 15
10 Having or improving knowledge or skills around LIs or promoting behavioural change (2—individual
HCP factors)
14
HCP, healthcare professional; LI, lifestyle intervention.
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information about the response rate and/or reasons for
non- response. In addition, the item on representative-
ness of the sample was often given an unknown rating
because insufficient information about the sample
and/or non- responders was presented. Finally, all three
mixed- methods studies had a negative rating since the
qualitative and quantitative components did not adhere
to their specific quality criteria. For the other four
mixed- methods criteria, only one of these three studies
obtained positive ratings.
Synthesis of results
A total of 809 factors were extracted from the 36
included articles. Table 2 presents the distribution of
factors from the individual studies across the afore-
mentioned nine domains, which were largely based
on the TICD checklist. The highest number of factors
was assigned to intervention factors (n=315), followed
by individual HCP factors (n=144), and patient factors
(n=137). The lowest number of factors was assigned
to capacity for organisational change (n=7), followed
by social, political and legal factors (n=9), and patient
and HCP interactions (n=19). In table 3, the content of
the nine domains is further explained by presenting an
overview of the created categories and subcategories of
factors that potentially influence the implementation of
LIs by HCPs within each domain. A full overview of all
extracted factors can be found in online supplemental
file 3 (presented per domain) and online supplemental
file 4 (presented per article).
Categories
The distribution of barriers and facilitators across the
various categories is presented in figure 2. The highest
number of barriers was assigned to the following five
categories: telehealth (n=40), collaboration (n=32),
expertise (n=32), accessibility (n=32) and treatment
expectations and preferences (n=31). The highest
number of facilitators was assigned to the following five
categories: telehealth (n=60), collaboration (n=46),
design (n=45), effectiveness (n=41) and role (n=28).
Subcategories
Tables 4 and 5 present the rankings of the ten largest
subcategories of barriers and facilitators respectively. The
first place in both rankings was assigned to a subcategory
related to interdisciplinary collaboration or healthcare
provision.
DISCUSSION
The aim of this review was to provide an overview of
barriers and facilitators that primary and secondary
HCPs perceive for implementing LIs in patients with hip
and/or knee OA. By linking the identified factors to a
framework that was largely based on the TICD check-
list,17 a comprehensive overview of influencing factors
was created that could serve as a basis for improving the
implementation of LIs within primary and secondary OA
care. The variety of domains shows that multiple levels (ie,
both the level of the individual HCP and several environ-
mental levels) should be considered in order to achieve
this. Within this framework, the extracted barriers were
most frequently related to non- optimal interdisciplinary
collaboration, a negative attitude of patients towards LIs,
low health literacy of patients, and a lack of knowledge
and skills of HCPs around LIs or promoting behavioural
change. The extracted facilitators were most frequently
related to good interdisciplinary collaboration, a posi-
tive perception of HCPs’ own role in implementing LIs,
the content or structure of LIs, and a positive attitude of
HCPs towards LIs.
A relatively large number of studies were included, a
majority of which was published in recent years. From
these 36 studies, a total of 809 influencing factors were
extracted. Although all nine domains were covered, the
total number of factors identified within each domain
differed greatly, ranging from 7 (capacity for organisa-
tional change) to 315 (intervention factors). In addition,
a large variation was found in the number of barriers
and facilitators between the various categories and
subcategories. However, we do not know yet whether
the established factor frequency is directly related to the
importance of the domain, category or subcategory in
question. So the fact that we found the highest number
of factors within certain domains, categories or subcate-
gories does not necessarily mean that these are the most
important or relevant in the context of implementation.
It could also be an indication that studies to date have
mainly focused on these aspects, and that the others are
still underexposed in the available literature. Therefore,
we recommend to take all domains into account in future
research in order to avoid missing factors that might
be highly relevant for the implementation of LIs. The
quality assessment of the included studies showed many
unknown ratings due to a lack of information about, for
example, the applied methods and their rationale. This
finding does not have to mean that the studies are of low
quality, but it does emphasise the importance of accurate
and complete reporting of research using design- specific
reporting guidelines.
Our results reflect those of a previous systematic review
conducted by Egerton et al,15 in which the authors synthe-
sised qualitative evidence only on primary care clinicians’
views on providing recommended management of OA up
to August 2016. In addition to exercise and weight loss,
recommended management included education, self-
management support, and medication. The authors iden-
tified four barriers as main themes (1): ‘OA is not that
serious’; (2) ‘clinicians are, or perceive they are, under-
prepared’; (3) ‘personal beliefs at odds with providing
recommended practice’ and (4) ‘dissonant patient expec-
tations’. A few system- related factors (eg, time, payment
system) were mentioned, but these were not found to be
themes across multiple studies. The added value of the
current review in comparison to the review by Egerton et
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al is that factors related to interdisciplinary collaboration
and the organisational and societal context were in fact
identified. Although these domains were relatively small
in terms of number of factors, the current review shows
that these factors can also influence the implementation
of LIs and thus offers an even broader perspective on the
implementation status of LIs within OA care. Besides an
expansion of the review’s scope (ie, the inclusion of quan-
titative data and the perspectives of secondary HCPs), this
broader perspective of our review most likely arises from
the date of the search. The vast majority (72%) of the
included articles were in fact published in the past 5 years
(after Egerton et al had conducted their review), which
shows that there is growing attention for the role of life-
style as treatment for hip and/or knee OA. Very recently
another scoping review has been published, conducted
by Nissen et al,63 which focused on clinicians’ beliefs and
attitudes about physical activity and exercise therapy as
treatment for hip and/or knee OA. The authors themat-
ically analysed qualitative data from four types of HCPs
(physiotherapists, general practitioners, orthopaedic
surgeons and rheumatologists). Their main finding is
that many clinicians perceive OA to be a low priority ‘wear
and tear’ disease. In addition, they identified a relative
lack of knowledge about and interest in physical activity
and exercise management among many clinicians. These
findings are also reflected in our results (especially in the
domains disease factors and individual HCP factors). In
addition, even more barriers and facilitators have been
identified in the current review. Compared with this
review by Nissen et al, our review again has a broader
scope (ie, the inclusion of weight management, quantita-
tive data and the perspectives of more types of HCPs) and
can therefore be seen as relevant addition to the existing
literature on this topic.
In addition to summarising the existing literature on
barriers and facilitators for implementing LIs, this review
aimed to identify potential gaps in literature on the partic-
ipation of HCPs. Although we aimed to include percep-
tions of various primary and secondary HCPs, the results
show that studies to date have mainly focused on the
views of physiotherapists and general practitioners. These
primary HCPs may well be the first point of contact for
patients within the care pathway, yet we recommend that
other relevant disciplines—like dieticians, lifestyle coun-
sellors, practice nurses and orthopaedic clinicians—be
more involved in follow- up research, allowing for a more
complete understanding of the patient journey in OA
care. Special attention should then be drawn to potential
differences in perceived barriers and facilitators between
types of HCPs, so that implementation strategies can be
tailored as much as possible to the various types of HCPs
and their clinical practice.
The resulting overview of barriers and facilitators can
be used to improve the implementation of LIs in daily
practice. This overview presents factors that are relevant
for individual HCPs, as well as for policy- makers, who can
facilitate the organisational and societal context in which
primary and secondary HCPs work. When developing
implementation strategies, possible interactions between
the various domains should also be considered. For
instance, more time (domain 5) can be used in various
ways by HCPs: for their own education (domain 2), provi-
sion of information to patients (domain 3), or interdisci-
plinary consultation (domain 4). Another example is that
societal changes in health insurance or payment struc-
tures (domain 7) can lead to increased accessibility of LIs
(domain 1), and that limited financial resources might
be less of an obstacle for patients (domain 3). Hence
changes related to the established factors can have posi-
tive effects on multiple levels.
Within the domain of intervention factors, a separate
category was created for factors specific to delivering LIs
via telehealth. Attention for this modality of healthcare
provision has been growing for some time.64 In addition,
during the course of the current review the COVID- 19
pandemic emerged, which meant that many HCPs
actually had to use telehealth in their daily practice.65
Although telehealth was not a specific focus of this review,
it could be interesting to further investigate the experi-
ences with telehealth and its value for long- term counsel-
ling of patients with hip and/or knee OA on behavioural
change.66
To the best of our knowledge, this is the first review
to focus specifically on the implementation of LIs as
conservative treatment for hip and/or knee OA while
taking into account the perceptions of all primary and
secondary HCPs involved. Both qualitative and quanti-
tative data were included, providing broad insight into
the topic. All included studies were conducted in North
America, Europe and Oceania. Given that the majority of
these studies were conducted quite recently, our results
are expected to be representative of the current situation
in these continents.
There are also a few limitations to acknowledge. First,
‘implementing LIs’ was defined very broadly and can be
seen as an umbrella term, ranging from mentioning a
healthy lifestyle to running specific lifestyle programmes.
Due to the heterogeneity of the included studies in terms
of study design and evaluated LIs, no distinction was
made between the different ways of implementing LIs
during data analysis. Consequently, the identified barriers
and facilitators may not fit with every single way of imple-
menting LIs, but may rather provide insight into the full
spectrum of influencing factors. Although data synthesis
has not been performed separately for physical activity
and weight management either, the created overview
gives us the overall impression that barriers and facilita-
tors related to these two lifestyle components are quite
similar. One barrier that seems to be unique to weight
management is the perception of it being a difficult or
sensitive subject to discuss. Regarding physical activity,
the perception that it is unsafe or has negative effects
seems to be a unique barrier. Second, although data
extraction and quality assessment were performed by two
researchers independently, data analysis was performed
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14 BoumaSE, etal. BMJ Open 2022;12:e056831. doi:10.1136/bmjopen-2021-056831
Open access
primarily by one researcher. By discussing the resulting
classification of factors and any doubts during the process
with members of the research team, we aimed to increase
the reliability of our findings. Third, the chosen cut- off
percentage for extracting quantitative data was based
on other scoping reviews combining the results of quan-
titative and qualitative studies.24 25 Therefore, there is a
chance that factors that would have been extracted when
using a lower cut- off percentage are missing. However, it
is also possible that these factors were already extracted
from the other included studies and therefore still
included in our results. Lastly, as we did not search grey
literature there is a slight chance that relevant studies
may have been missed.
The comprehensive overview of barriers and facilitators
for implementing LIs in patients with hip and/or knee
OA by HCPs resulting from this review can serve as a basis
for further research and the development of implemen-
tation strategies that focus on both the individual and the
environmental context of HCPs. However, what the rela-
tive importance of the identified factors is and whether
differences exist between the various types of primary
and secondary HCPs with respect to these factors are not
known yet. Further research is required to provide more
insight into this relative importance and therewith the
most relevant targets for change in daily practice.
CONCLUSION
This review has shown that multiple factors influence
whether or not HCPs implement LIs when treating
patients with hip and/or knee OA. Data analysis has
resulted in a comprehensive overview of influencing
factors, where barriers and facilitators have been subdi-
vided into nine domains, both at an individual and at
several environmental levels. The review contributes to
existing knowledge about the implementation of LIs by
identifying multiple factors related to the intervention,
interdisciplinary collaboration and the organisational
and societal context. The broad inventory created in this
review can be a first step towards an improved implemen-
tation of LIs by HCPs in OA care. Future research in this
area should focus on determining the relative importance
of the identified factors involving all relevant disciplines
of primary and secondary HCPs.
Author afliations
1Department of Orthopedics, University of Groningen, University Medical Center
Groningen, Groningen, The Netherlands
2Center for Human Movement Sciences, University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
3Department of Rehabilitation Medicine, University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
4Peter Harrison Centre for Disability Sport, School of Sport, Exercise and Health
Sciences, Loughborough University, Loughborough, UK
Acknowledgements The authors would like to thank Truus van Ittersum for her
advice on search strategies and Annemarie Jenks for her contribution to the study
selection process.
Contributors Conception and design: SB, RD, LHVvdW, MS and IvdA- S. Collection
and assembly of data: SB and JvB. Analysis and interpretation of the data: SB, MS
and IvdA- S. Drafting of the article: SB. Critical revision of the article for important
intellectual content: SB, JvB, RD, LHVvdW, MS and IvdA- S. Final approval of the
article: SB, JvB, RD, LHVvdW, MS and IvdA- S. Obtaining of funding: SB, RD, LHVvdW,
MS and IvdA- S. Guarantor: SB.
Funding This study is supported by a scholarship from the University of Groningen/
University Medical Center Groningen (grant/award number: not applicable).
Competing interests None declared.
Patient consent for publication Not applicable.
Ethics approval This study does not involve human participants.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data sharing not applicable as no datasets generated
and/or analysed for this study.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer- reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See:https://creativecommons.org/
licenses/by/4.0/.
ORCID iDs
Sjoukje EBouma http://orcid.org/0000-0002-8056-6586
Ron LDiercks http://orcid.org/0000-0001-9873-208X
Lucas H Vvan der Woude http://orcid.org/0000-0002-8472-334X
MartinStevens http://orcid.org/0000-0001-8183-6894
Ingevan den Akker- Scheek http://orcid.org/0000-0002-1614-8419
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Questions What are the experiences of physiotherapists delivering care for people with knee osteoarthritis? How do these experiences align with the national Clinical Care Standard? Design A qualitative study using individual interviews. Participants Twenty-two Australian physiotherapists (mean age 34 years, 50% female) with experience in providing care for people with knee osteoarthritis. Methods Physiotherapists participated in semi-structured individual telephone interviews. Questions were informed by seven quality statements from the national Knee Osteoarthritis Clinical Care Standard. Thematic analysis was undertaken, with themes/subthemes inductively derived. Interview data were also deductively analysed according to the Clinical Care Standard. Results Five themes emerged. First, physiotherapists focused on biomedical assessment with little psychosocial consideration. They managed ‘mechanical’ aspects of knee osteoarthritis, aiming to restore functional ability. Second, physiotherapists’ perceived their role as primarily providing goal-orientated personalised exercise via short-term episodic care. Knee surgery was considered a last option, but physiotherapists ‘prepped’ patients who decided on surgery. Third, clinical challenges included patient comorbidity, unsatisfactory patient adherence and a patient’s desire for a ‘quick fix’. The other two themes were: physiotherapists described a mismatch between what they know and what they do regarding imaging, weight management and manual therapy; and physiotherapists viewed weight loss, medication and surgical advice as outside of their professional role. Conclusion Physiotherapists’ reported experiences of delivering care for people with knee osteoarthritis were mostly consistent with the quality care standard. Care may be improved by increasing the focus on psychosocial aspects of care, offering longer-term reviews, and being more proactive with advice and/or referral regarding weight loss, pain medications and knee surgery. By describing the potential benefits and harms of common osteoarthritis medications and surgical interventions, physiotherapists will ensure that their patients are fully informed about all their treatment options.
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Objective To explore clinicians’ attitudes and beliefs about physical activity and exercise therapy as treatment for individuals with knee and/or hip osteoarthritis (OA). Method This was a scoping review, mapping available knowledge about the topic derived from qualitative research designs and methods. A comprehensive search of selected databases (MEDLINE, EMBASE; CINAHL; Web of Science) was conducted and data were analysed thematically. Results Twelve articles met inclusion criteria. Thematic analysis identified three interrelated main themes: 1) Understandings of OA and its trajectory and management; 2) Attitudes to activity and exercise as part of OA management; 3) Clinicians’ perceived knowledge of and expertise in OA management. Findings highlight that many clinicians involved in knee/hip OA management, particularly general practitioners and physiotherapists, perceive OA to be a low priority ‘wear-and-tear’ disease with expected progression of symptoms, making joint replacement surgery eventually inevitable. Further, many clinicians appear to lack knowledge about and interest in physical activity and exercise therapy in the management of knee/hip OA, and seem to show uncertainty about the effectiveness and safety of physical activity and exercise therapy on joint health. Conclusion Clinicians’ attitudes and beliefs about physical activity and exercise therapy in OA seem to reflect an outdated narrative which describes OA as a wear-and-tear disease with inevitable disease progression to joint replacement surgery. Clinicians need to adopt a contemporary narrative, which accurately reflects current knowledge and evidence-based practice, thereby ensuring consistent utilisation of exercise therapy as first-line care as recommended in OA guidelines.
Article
(250 words) Objective Explore patient and dietitian experiences with a multi-component dietary weight loss program for knee osteoarthritis to understand enablers and challenges to success at 6-months. Design Qualitative study embedded within a randomised controlled trial. Semi-structured individual interviews with 24 patients with knee osteoarthritis who undertook, and five dietitians who supervised, a weight management program (involving a ketogenic very low calorie diet (VLCD), video consultations, educational resources) over six months. Data were thematically analysed. Results Five themes were developed: i) ease and convenience of program facilitated adherence (structure and simplicity of the meal replacements; not feeling hungry on diet; convenience of consulting via video) ii) social and professional support crucial for success (encouragement from partner, family, and friends; guidance from, and accountability to, dietitian; anxiety around going at it alone) iii) program was engaging and motivating (determination to stick to program; rapid weight loss helped motivation) iv) holistic nature of program was important (suite of high-quality educational resources; exercise important to compliment weight loss) v) rewarding experience and lifelong impact (improved knee pain and function; positive lifestyle change). Conclusions Patients and dietitians described positive experiences with the weight management program, valuing its simplicity, effectiveness, and convenience. Support from dietitians and a comprehensive suite of educational resources, incorporated with an exercise program, were considered crucial for success. Findings suggest this multi-component dietary program is an acceptable weight loss method in people with knee osteoarthritis that may benefit symptoms. Strategies for supporting long-term independent weight management should be a focus of future research.
Article
Objective: Explore challenges associated with implementing a home-based strengthening exercise program for people with knee osteoarthritis and comorbid obesity. Methods: Qualitative study embedded within a randomised controlled trial comparing two home-based strengthening programs (weight bearing functional exercise versus non-weight bearing quadriceps strengthening exercise) for people with knee osteoarthritis and comorbid obesity. Patients in both exercise programs attended five consultations with a physiotherapist and undertook a home-based exercise program for 12 weeks. Semi-structured individual telephone interviews were conducted with 22 patients after trial completion, and all seven physiotherapists who delivered trial interventions. Interviews were recorded, transcribed verbatim, and thematically analysed using an inductive approach. Results: Three themes arose: i) psychological challenges (false assumptions about exercise; fear of pain; disliking exercise; mental effort of weight bearing functional program; underestimating capability) ii) physical challenges (complexity of weight bearing functional program; cuff weights and straight leg raise problematic in non-weight bearing quadriceps program; other health conditions), and; iii) overcoming challenges (incentives to exercise; accountability; education and reassurance; tailoring the exercise program). Conclusion: Patients and physiotherapists experienced numerous psychological and physical challenges to exercise, including a fear of pain, having false assumptions about exercise, difficulties with exercise performance, application of cuff weights, and adverse impacts of other health conditions.
Article
Background Knee and hip osteoarthritis (KHOA) are common, chronic conditions affecting function, morbidity, and mortality. Although the societal burden is high and guidelines are available to guide management, many patients do not receive recommended care. We investigated patient and physician perspectives on barriers and facilitators to KHOA guideline‐based treatment, and patient experiences in living with KHOA and navigating care. Methods Thirty‐minute face‐to‐face interviews were conducted with primary care physicians and up to four patients of each physician at a U.S. academic medical center. Physicians were recruited from one general internal medicine clinic and one family medicine clinic. All of their patients diagnosed with knee or hip osteoarthritis from 2008‐2011 and under their care during the study period (2008‐2015) were mailed study recruitment materials. Interviews were audio‐recorded and transcribed. Content analysis was performed using QSR NVivo. Results Six of 19 physicians (31.6%) responded to the recruitment email and completed the interview. Seventy‐three patients were sent recruitment letters; 18 (24.7%) expressed interest and 11 were scheduled for and completed the interview. Many patients reported a poor understanding of osteoarthritis and available treatment options, and obtained most of their information from sources other than their medical team. They expressed fear of joint pain and often modified activities to avoid all pain. Many developed complex, time intensive treatment regimens that were not always evidence‐based. Physicians expressed difficulties in managing osteoarthritis given time constraints and competing agenda items at appointments. Many felt that asking patients to make lifestyle changes for weight loss and exercise was daunting and unachievable. Both physicians and patients expressed interest in obtaining osteoarthritis education. Conclusions Although evidence‐based treatments for KHOA exist, our study highlights patient and physician barriers to receipt of this care. Better educational resources and new models of care to address these barriers may contribute to improved osteoarthritis management.
Article
Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. During the COVID-19 pandemic, healthcare systems have begun crisis management planning. To appropriately allocate resources and prevent virus exposure while maintaining effective patient care, our orthopaedic surgery department rapidly introduced a robust telemedicine program during a 5-day period. Implementation requires attention to patient triage, technological resources, credentialing, education of providers and patients, scheduling, and regulatory considerations. This article provides practical instruction based on our experience for physicians who wish to implement telemedicine during the COVID-19 pandemic. Between telemedicine encounters and necessary in-person visits, providers may be able to achieve 50% of their typical clinic volume within 2 weeks. When handling the massive disruption to the routine patient care workflow, it is critical to understand the key factors associated with an accelerated introduction of telemedicine for the safe and effective continuation of orthopaedic care during this pandemic. LEVEL OF EVIDENCE:: V.
Article
Objective: The study aimed to understand how physical therapists used practice guidelines to manage patients with knee OA in Australia. Methods: This study used a concurrent triangulation mixed method approach to explore how physical therapists applied clinical guidelines when managing patients with knee OA in an outpatient setting via completion of a semi-structured interview. Interviews were thematically analysed by 2 investigators using an inductive approach. Themes were then triangulated to the results of an audit that evaluated the level of adherence to respective areas in the clinical guidelines among physical therapists at the participating site. Results: One main theme and 3 subthemes were identified from 18 participants: i) physical therapists were most confident in applying guidelines to improving range of movement and strength, ii) lack of knowledge in prescription of aerobic exercise, weight and pain management, iii) pain is a bigger barrier in areas where knowledge is lacking, iv) lack of clarity around the scope of practice. Themes converged with the reported level of adherence to guidelines. Conclusions: Physical therapists commonly include range of movement and muscle strength exercises when managing people with knee OA. However, they were less confident in prescribing aerobic exercise and recommending weight and pain management strategies. Impact: Apart from the need to upskill physical therapists in the aforementioned areas of clinical practice, the role of a physical therapist in the management of people with knee OA requires further clarification.